New Home Remedy to Cure Sleep Apnea

Sleep Apnea

Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?

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Cure Sleep Apnea Without Cpap

In these real-life case studies youll learn in-depth about the lives and treatments of 9 people who have conquered their apnea. Specifically, youll learn: 1. When they first suspected they had sleep apnea. 2. Symptoms that made them first think they had sleep apnea. 3. Steps they took to get diagnosed. 4. How they felt when they were diagnosed (what was going through their mind) 5. The quality of their sleep before their apnea treatment, and how they felt during the day. 6. What they did to try to get a good nights sleep before their successful treatment. 7. What they did to try to overcome fatigue during the day. 8. A description of exactly what their treatment involved. 9. How they found out about the treatment. 10. Side effects of their treatment. 11. Obstacles they encountered during their treatment, and how they overcame those obstacles. 12. How long it took before the quality of their sleep improved. 13. How long it took before they felt better (more rested) during the day. 14. How long its been since they conquered their sleep apnea. 15. Resources they recommend for others who suffer from sleep apnea, and would like to follow their treatment (the name of specific doctors and medical centers) 16. Final words of advice for people who have just been diagnosed with sleep apnea. Here Is a Tiny Sample of What Youll Get When You Download Your Copy Of Cure Your Sleep Apnea Without Cpap: 78 pages of actionable information on alternative, non-Cpap sleep apnea treatments. 9 case studies of men and women who have completely cured their sleep apnea without Cpap. 7 types of alternative treatments that are proven to cure sleep apnea (detailed descriptions) 12 action steps for each alternative treatment, so you know exactly how to take action on each treatment. 7 quick fix sleep treatments that can help you get a better nights sleep Tonight. 69 hand-picked web links for further information on alternative sleep apnea treatments. 31 diagrams explaining alternative sleep apnea treatments

Cure Sleep Apnea Without Cpap Summary

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Easy Sleep Apnea Treatment Singing Exercises

The Singing for Sleep Apnea program provides step-by-step instructions on which singing exercises to follow. Each exercise uses sounds and tunes selected for the strong movements they cause in key areas of your upper airway. The aim of these exercises is pharyngeal fitness: a toned, athletic pharynx that is no longer predisposed to collapse and vibrate in sleep; and which is also wider, resulting in a gentler, less turbulent breath. The exercises are also designed to be fun and to raise your spirits! This complete package includes the following to help you learn the singing exercises as quickly as possible: a) A no-fluff 25-page guide with all you need to know to start your singing exercises, including step-by-step instructions on how to do 13 targeted singing exercises, tips on how to prepare for the singing exercises and how to get the most out of this program (in plain English!) b) 13 instructional audios by noted singing teacher Emily Tucker. These audios have been created specifically for sleep apnea sufferers, and provide step-by-step instruction on each individual singing exercise. c) Bonus ebooks on overcoming insomnia and proven sleep hygiene techniques.

Easy Sleep Apnea Treatment Singing Exercises Summary

Contents: 25 Page EBook, 13 Audios, Bonus EBooks
Author: Marc MacDonald, Emily Tucker
Official Website: www.singingforsleepapnea.com
Price: $47.00

The rise of sleep medicine

Although this was not a focus of their work, Aser-insky and Kleitman's original description of REM sleep included the recognition of concomitant changes in cardiorespiratory measures. As has been extensively demonstrated over the past 50 years, virtually every physiological system of the body undergoes a change of state over the sleep-wake cycle (see Chapter 3 Neurophysiology and neuroimaging of human sleep). Subsequent investigation has led to the recognition that such sleep-related changes may be unhealthy and in some individuals are clearly pathological. For example, respiratory commands may not be issued (central sleep apnea) and or the commands may become blocked (obstructive sleep apnea) with deleterious effects on sleep itself and upon cardiorespiratory functions generally (see Chapter 7 Sleep-related breathing disorders).

Primary Nursing Diagnosis

Incentive spirometry, chest percussion, and postural drainage may be prescribed by the physician to increase gas exchange and to decrease the risk of atelectasis. Oxygen may be delivered with humidification to improve clearance of mucus. If atelectasis persists, the physician may prescribe a mask with continuous positive airway pressure (CPAP). With the use of a CPAP mask, positive airway pressure is maintained throughout the respiratory cycle. In addition, CPAP prevents and reverses airway closure, thus expanding the lung volumes and reestablishing the functional residual capacity (FRC). If atelectasis persists and hypoxemia becomes life-threatening, endotracheal intubation and mechanical ventilation with positive-pressure ventilation and positive end-expiratory pressure (PEEP) may be necessary, but these aggressive therapies are usually not needed.

Clinical tests to establish daytime sleepiness

Sleep-related complaint reported by patients seen in sleep disorder centers 47 . Sleepiness can be caused by sleep deprivation, sleep fragmentating disorders (e.g. sleep apnea) 48 , disorders of central hypersom-nolence (e.g. narcolepsy), or certain types of medications 49 . Decreased productivity, problems in interpersonal relationships, and increased risk for motor vehicle accidents are some of the most common consequences of excessive sleepiness 50 .

Integrated Ventilatory Responses

Integrated ventilatory responses to changes in activity and the environment illustrate many important interactions between elements of the respiratory control system. Such interactions are typical in patients, and the physician needs to understand them to make an intelligent diagnosis and provide appropriate treatments. The most common stimulus to increase ventilation in healthy subjects is exercise. Relatively common problems in control of ventilation during sleep are described in the Clinical Note on sleep apnea. The next sections compare and contrast the integrative response to chronic hypoxemia in normal subjects during acclimatization to high altitude and patients with lung disease.

Clinical Note continued

Obstructive apnea can occur when reflexes do not respond to the normal negative pressure in the upper airways during inspiratory flow and induce the normal contractions of upper airway muscles to support the airways in an open position. Increased inspiratory effort, for example, in response to chemoreceptor stimulation, makes the tendency for airway collapse worse if the upper airways do not respond also. Therefore, the fundamental problem in obstructive apnea is a lack of coordination between the inspiratory and upper airway muscles and this is worst in REM sleep. The most effective treatment for obstructive apneas is nasal continuous positive airway pressure (nasal CPAP). This treatment applies a positive pressure to the upper airways by a mask fitted over the nose of the sleeping patient, to counteract the decrease in airway pressure during inspiration and support the airways in an open position. Sleep apnea also occurs in other conditions also. High-altitude sleep apnea may occur...

Dreams and sleep disorders

This section will focus on several sleep disorders which have been studied in relation to dreaming insomnia, sleep apnea syndrome, narcolepsy, and restless legs syndrome. For other diagnoses, like idio-pathic hypersomnia, or NREM parasomnias, such as In sleep apnea, the findings regarding the dream recall frequency are inconsistent (cf. 76 ). In the nineteenth century, nightmares were thought to be due to decreased flow of oxygen (e.g. due to pillow blocking of the mouth and nose see 77 ). However, parameters like minimal oxygen saturation nadir or respiratory disturbance index do not correlate with dream recall frequency 78 . Furthermore, a heightened nightmare frequency in sleep apnea patients has not been found 76 . Only very few dream reports include the massive physiological apnea processes (Patient with sleep apnea, male, 39 years, respiratory disturbance index (RDI) 68.1 apneas per hour, maximal drop of blood oxygen saturation 43 ). Overall, the low incidence of...

Scales and inventories

A few of the more commonly utilized inventories have already been described, including the insomnia severity index, the fatigue severity scale, the Epworth sleepiness scale, sleep diaries, and the Mallampati airway classification. The STOP-bang scoring model 35 is a method that was recently introduced, which strives to predict the risk of OSA without the use of polysomno-graphy, the gold-standard procedure for the diagnosis of the disorder (Figure 6.6). It includes elements of the history and physical examination, and was validated in preoperative patients. Yes answers to three or more questions place the patient at high risk for OSA. The questionnaire was validated in a mixed group of preoperative patients against in-lab polysomnography. Sensitivities and specificities of the questionnaire are, respectively, as follows for mild OSA (apnea-hypopnea index, or AHI, between 6 and 15), 83.6 and 56.4 for moderate OSA (AHI between 16 and 29), 92.9 and 43.0 for severe OSA (AHI greater than...

Sleeprelated breathing disorders

Sleep-related breathing disorders are characterized by disturbed respiration during sleep. These respiratory events may range from recurrent mild upper airway constriction (called upper airway resistance syndrome) to recurrent total obstruction. SRBDs are subdivided into those with obstruction (obstructive sleep apnea) and those with diminished or absent respiratory effort (central sleep apnea). In addition, there may be a mixture of these components (mixed type). Within these categories, there is a continuum in the degree of obstruction and in the frequency of these obstructive or central events. A great deal of work has gone into defining the epidemiology of these disturbances and their associated risks and pathophysiologies. Obstructive sleep apnea (OSA) is a chronic condition characterized by repetitive upper airway obstruction during sleep leading to apneic episodes, hypoxemia, and recurrent arousals from sleep 2 . It has been estimated that 2 to 4 of middle-aged men and 1 to 2...

Psychiatric presentations of OSA

The cardinal symptom of OSA is excessive daytime sleepiness, which appears to be related to recurrent arousals from sleep associated with obstructive events 14 . Other associated signs and symptoms include snoring, unrefreshing sleep, nocturnal choking (or dreams about choking or drowning), witnessed apneas, nocturia, morning headaches, mild cognitive impairment, and reduced libido 2 . Diagnosis is confirmed by assessment of sleep, typically via polysom-nography. While exact cut points are arbitrary, a mean of 5-15 obstructive events per hour of sleep represents mild dysfunction, 15-30 events per hour represents moderate dysfunction, and > 30 events per hour represents severe dysfunction 15 . Treatment options for OSA include weight loss, including discontinuation of weight-increasing medications, positional therapy, continuous positive airway pressure (CPAP), and mandibular advancement devices or surgery for clearly identifiable causes of upper airway obstruction 14 . The first...

Bariatric Surgery Surgery to Promote Weight Loss

When bariatric surgery is performed in people with type 2 diabetes, 60 percent or more have normal blood glucose levels without medications, and the others can use fewer medications. There is also improvement in the lipid profile, blood pressure, and sleep apnea. The National Institutes of Health recommend that bariatric surgery is one option that should be considered if a person has extreme obesity (BMI greater than 40) or if a person has diabetes and a BMI greater than 35.

Effect of treatment on cognitive and performance impairments

Studies, CPAP treatment had a moderate to large effect on cognitive processing, memory, sustained attention, and executive functions 38 . However, other studies show persistent cognitive deficits despite treatment 62,63 . The majority of controlled clinical trials evaluating the efficacy of CPAP treatment have enrolled predominantly moderate to severe OSA patients. In mild OSA patients, the only improvement in quality of life after 8 weeks of CPAP treatment was in vitality 64 . Some studies suggest that beneficial CPAP treatment effects for cognition might be attributable to changes in the underlying level of daytime sleepiness 64,65 . Bardwell and colleagues evaluated the effectiveness of 1-week CPAP treatment versus placebo-CPAP (i.e. CPAP administered at subtherapeutic pressure) on cognitive functioning in patients with OSA. Although CPAP improved overall cognitive functioning, no beneficial effects in any specific domain were found. But, only 1 of the 22 neuropsychological test...

Cytokine and metabolicrelated hormone studies

It has been suggested that some of the psychological symptoms experienced by OSA patients may be related to high levels of proinflammatory cyto-kines. Vgontzas and colleagues reported that the inflammatory cytokines tumor necrosis factor-a (TNF-a) and interleukin-6 (IL-6), which produce sleepiness and fatigue, are elevated in sleep apnea and obesity and might play a role in the pathogenesis and pathological sequelae of both disorders 107 . Haensel and colleagues found that elevated levels of the soluble tumor necrosis factor receptor 1 (sTNF-R1) were significantly correlated with cognitive dysfunction in untreated OSA patients. They suggest that inflammation in OSA may be an important factor to Continous Positive Airway Pressure (CPAP) Treatment Obstructive Sleep Apnea - apneas hypopneas - non-compliance with CPAP Figure 7.4 A schematic summary of a research modelusing obstructive sleep apnea (OSA) for studying sleep and cytokines. CPAP, continuous positive airway pressure SNS,...

Treatment effects on depression in OSA

Studies of CPAP's treatment effect on depressive mood are not consistent. Table 7.1 summarizes studies reporting the impact of CPAP treatment (for over 1 month of treatment) on depression and anxiety. Many studies reported that depressive symptoms were ameliorated by CPAP treatment. It is gratifying to see that this field is attracting careful study. At the risk of merely counting positive versus negative studies, it appears that more studies (i.e. 14 studies) report positive effects of CPAP on mood as compared to non-significant effects on mood (i.e. 6 studies). Differences in experimental design such as sample size, the nature of depressive symptoms, CPAP compliance, and co-morbid medical conditions need further exploration. In some negative studies, baseline depressive symptoms were not particularly high, and one could speculate that the lack of a treatment effect on depression was due to a floor effect 22 . Millman and colleagues found that OSA patients with more severe depressive...

Opioids and antiepileptics

If treatment of RLS with a dopamine agonist is unsuccessful or contraindicated, there are several other agents that can be used. Opioids are clinically effective in RLS, however are regarded as second-line treatment in RLS as controlled studies are still lacking. The one double-blind randomized trial with oxycodone revealed a mean dosage of 15 mg reduced sensory and motor symptoms and was well tolerated 77 . In an observational study, tramadol was effective in RLS at a dosage of 50-150 mg day 78 . Opioids seem to have a long-term efficacy in the treatment of RLS and are generally well tolerated 79 . Clinical or polysom-nographic monitoring for the development of sleep apnea is, however, recommended in patients on long-term opioid therapy 80 .

Clinical Development of Aldurazyme

Stiffness, the airway problems with associated sleep apnea, respiratory insufficiency, the diverse cardiac problems, recurrent infections, and the eye disease. Other compound clinical problems that were studied, but with more difficulty, included the fatigue malaise, severe headaches, the enlarged tongue, and signs of cord compression. Besides clinical measures, the elevated level of GAG in the urine, which reflects excessive renal distal tubular storage, is commonly used as a screen for MPS disease as well. To establish the possible treatment effects that could be measured in the initial clinical study, the data from the preclinical studies in the MPS I dog with rhIDU, the reports of BMT in MPS I, and the first published clinical study of Ceredase in Gaucher's disease were reviewed. Based on the data from the MPS I dogs undergoing enzyme therapy, both liver storage and urinary GAG were found to be effective measures of lysosomal storage that did accurately reflected the storage in...

Phase 1 Open Label Study in Ten Mps I Patients 12711 Study Objectives and Design

The first study of Aldurazyme was designed as an open-label study of weekly intravenous infusions of rhIDU at a dose of 0.58 mg kg in 6 to 10 patients of age 5 years or greater and representing a wide range of disease severity 12 . Given the open-label design, only objectively measured clinical endpoints were proposed, and the analysis was based on comparing pretreatment with posttreatment measurements for the various endpoints. The primary endpoint variables were quantitative measures of storage, including liver or spleen size and urinary GAG excretion. Liver or spleen size is enlarged in MPS I due to storage, and a reduction in organ size was measured by MRI. Urinary GAG excretion is elevated in MPS I patients, and a reduction in urinary GAG excretion would represent a reduction in renal storage. Secondary endpoint variables included sleep apnea, shoulder, knee, and elbow maximum range of motion, cardiac evaluations (a scoring system of history, physical, echocardiography findings,...

Study Results in the Clinical Manifestations

Evaluation of range of motion showed that there were improvements in shoulder flexion, elbow extension, and knee extension that increased with time over 104 weeks. Sleep apnea declined 61 by 26 weeks, and the three patients with the most clinically severe sleep apnea all improved. NYHA classifications improved at least one class in all patients by 52 weeks. Visual acuity improved in the three patients with the worst vision. Height and weight growth velocity increased 85 and 131 , respectively, in the six prepubertal patients.

Phase3 Study of Aldurazyme 12721 Study Objectives and Design

The phase-3 study was designed as a randomized, double-blind, placebo-controlled study in 45 MPS I patients treated with weekly infusions of Aldurazyme over a 26-week period 13 . The patient population was restricted to patients over 5 years of age and was predominantly Hurler-Scheie in phenotype. The primary endpoints were the change between baseline and week-26 in the forced vital capacity (FVC), and the 6-min walk test. FVC is a measure of lung capacity, which is severely restricted in MPS I patients such that respiratory insufficiency is a common contributor to death. The 6-min walk test is commonly used in congestive heart failure studies as a measure of endurance. In MPS I, the 6-min walk distance can be severely restricted due to a combination of factors that includes poor respiratory function, cardiac disease, and joint stiffness and pain. In addition to these endpoints, secondary endpoints in the study were liver size, sleep apnea, shoulder flexion, and the Health Assessment...

Study Results in Other Endpoints

Sleep apnea was assessed using polysomnograms and the apnea-hypopnea index, a measure of the number of apneic or hypopneic events per h during sleep. When all patients were included, the treated patients had a decrease of about 3.6 events per h (p 0.145). When only patients with clinically significant sleep apnea at baseline were included, the treated patients with sleep apnea (n 10) had a decrease of 6.0 events per h whereas the affected placebo patients (n 9) had an increase of 0.3 events per h. The 11.4 events per h difference (adjusted by ANOVA) between the treated and placebo groups of patients with sleep apnea at baseline was statistically significant (p 0.014). For shoulder flexion, there was no significant difference in the overall group comparison, but for patients with more significant restriction of shoulder flexion at baseline (below the median of 90.5), the treated patients improved 9.6 whereas the placebo patients decreased 4.8 . The Health Assessment Questionnaire did...

Regulatory Strategies and Challenges with Surrogate Endpoints

Surrogate endpoints to the reduction of clinical disease in other tissues, but in the end, animal studies are not given significant weight in these assessments. Even with the combination of the data and information noted above, but without solid and convincing data from human clinical studies that demonstrated correlations between the surrogates and clinical parameters, the surrogates would not be considered likely to predict clinical benefit. In the end, the primary efficacy data on liver size and urine GAG excretion with the strong statistical significance was not accepted as sufficient. The clinical data from the first trial (joint range of motion, sleep apnea, etc.) were considered to be not interpretable because there was no control group and the measures could be affected by the evaluator or operator. A second study was needed. The key added features required were a doubleblind, placebo control and a multicenter design to ensure that inadvertent bias did not alter the results....

Advisory Committee Preparation and Execution

The main message of the briefing document from the sponsors was that MPS I was a heterogeneous and complex chronic disease with components of disease that were reversible and others that were not reversible. It is also stated that the treatment effects observed affected multiple systems within the same patients in many cases, and that the totality of the benefit from improved FVC, decreased sleep apnea, increased walk endurance, and improved range of motion must be appreciated as a synthesis of clinical benefits and within the context of a chronic disease without significant therapy.

Congestive heart failure

Patients with heart failure suffer from sleep-related breathing disorders 70 . A recent study showed that at least 21 of patients with congestive heart failure complained of EDS, and 48 complained of being awake more than 30 minutes during the course of the night 71 . Screening for sleep-related breathing complaints, referral, and treatment of any central or obstructive sleep apnea often improves alertness and well-being in these patients.

Sleepwalking and sleep terrors overview and clinical description

Sleepwalking (SW) represents motor activation during an abnormal arousal, usually from deep NREM sleep. Common during childhood (1-17 ), SW tends to diminish in frequency following adolescence but can persist into or even begin during adult life (2.5 ) 15,16 . Behaviors can vary from sitting up in the bed to full ambulation. Behaviors can be very complex and include walking, running, driving, eating, and violence. Mental activity is usually poorly recalled but may include dream-like visual imagery, which tends to be both less detailed and less bizarre than traditional REM dream reports. Individuals are variably amnestic for the episodes. Typically occurring during the early part of the sleep cycle and emerging from the deeper stage N3 of NREM sleep, they may technically derive from any NREM stage. Many individuals report that frequency and severity of sleepwalking increase with stressful life experiences. Cases have been associated with migraine and thyrotoxicosis 17,18 . There is...

Classification of Epimutations

Characterized by neonatal muscular hypotonia, hypogonadism, hyperphagia and obesity, short stature, small hands and feet, sleep apnoea, behavioural problems and mild to moderate mental retardation (estimated prevalence, 1 25,000 newborns). PWS is caused by the loss of function of imprinted genes which are active on the paternal chromosome only. Although all of the genes in the critical region are known, it is unclear which are the PWS genes. In patients with an imprinting defect, which is found in approximately 1 of cases, all paternally expressed genes are silent. Of these patients, 10 have a PWS-SRO deletion, whereas 90 have a primary epimutation (see Sect. 2.2). Almost all of the other PWS patients have a large paternally derived chromosomal deletion, or maternal uniparental disomy.

Clinical Uses Of Electrical Stimulation

Electrical stimulation of the phrenic nerve or the diaphragmatic muscles is used to support ventilation. Candidates for breathing pacing include patients who require chronic ventilatory support because of spinal cord injury, decreased day or night ventilatory drive (e.g., sleep apnea), intractable hiccups (chronic hiccups often lead to severe weight loss and fatigue and can have fatal consequences), and damaged phrenic nerve(s). The physiological respiratory function provided by these devices is far superior to that provided by mechanical ventilators since the air inhaled is drawn into the lungs by the musculature rather than being forced into the chest under mechanical pressure.

Evaluation of the patient with EDS

If a thorough history and physical examination raises suspicion of disorders such as periodic limb movements, obstructive sleep apnea, nocturnal seizure, or parasomnia, then nocturnal polysomnography (PSG) - overnight sleep study - may be indicated to either rule out sleep disturbances or to quantify their severity. This is typically related to sleep disorders that produce sleep fragmentation or sleep inefficiency including sleep-related breathing disorders, periodic limb movement disorder, REM sleep behavior disorder, other sleep-related movement disorders, parasomnias, or nocturnal seizures.

Floppy Eyelid Syndrome

Floppy Eyelid Syndrome

The cause of the disease remains unknown and histological examination of the softened and redundant tarsal plate has not suggested any conclusive etiology. A mild chronic inflammatory infiltrate has been reported in some cases, but it is not clear if this was a primary cause or a secondary effect. The tarsal plate and skin show a decreased amount of elastin fibers. The syndrome and its clinical spectrum results from loss of physical integrity of the tarsus, perhaps in part related to habitual sleeping on the involved sides in patients with excessive weight. The condition is also associated with obstructive sleep apnea.

Nursing Diagnoses Ineffective Airway Clearance

Assess respirations for rate (count for one full minute), depth and ease, presence of tachypnea (specify), dyspnea and if it occurs during sleep or quiet time note panting, nasal flaring, grunting, retracting, slowing, deep (hyperpnea) or shallow (hypopnea) breathing, stridor on inspiration, head bobbing during sleep (specify frequency).

Epidemiology of restless legs syndrome and periodic limb movement disorder

PLMS per se are not a diagnosis but a polysomno-graphic finding which is observed during sleep studies in various diseases and even in the healthy elderly. In fact, the prevalence of PLMS increases with advancing age (for review see also 20 ). It is critical to note that PLMS and PLMD are not synonymous, the latter implying a sleep disturbance that is caused independently by PLMS. The largest epidemiological study on PLMD to date documented a 3.9 prevalence in 18 980 subjects aged from 15 to 100 years in the general population using the International Classification of Sleep Disorders (ICSD) criteria in a telephone interview survey 21 . Furthermore, the study identified several factors associated with PLMD, such as female gender, coffee intake, sleep apnea syndrome or snoring, stress, and the presence of mental disorders 21 . However, this study did not employ sleep studies but was based on self-reported leg movements, and thus its findings should be considered preliminary.

Physiological changes occurring in sleep stages

During NREM and tonic REM sleep the sympathetic activity (fight or flight) of the ANS decreases 14 , whereas the parasympathetic activity (rest and repose) progressively increases until it peaks in deep sleep (SWS) 15 , where blood pressure and heart and respiratory rates reach their lowest values 16 . Notably, increased sympathetic activation observed in individuals affected by sleep apnea, a condition characterized by chronic SWS deficits, may theoretically increase their risk of developing diabetes 17 . Abnormal peaks of sympathetic activity have also been reported during phasic REM in patients affected by melancholic depression, although their relationship with this psychiatric disorder is not clear 18 . During sleep, air exchange decreases because of the loss of waking-related respiratory drive and a reduction in respiratory rate and minute ventilation. At the same time, the resistance in the upper airways increases as a result of muscle relaxation 21 . Reduced sensitivity of...

Editors introduction

The value to psychiatrists of understanding sleep medicine has become increasingly evident over the past 20 years. The neuropsychiatric sequelae of primary sleep disorders such as sleep-related breathing disorders, sleep-related movement disorders, and circadian rhythm sleep disorders are increasingly recognized. In addition, psychotropic medications prescribed to treat psychiatric illness may inadvertently induce or exacerbate primary sleep disorders such as REM behavior disorder, obstructive sleep apnea, and restless legs syndrome, leading to unsuccessful treatments, paradoxical responses, or unwanted unintended side-effects. Furthermore, psychotropic medications prescribed for the management of sleep-related symptoms presumed to be inherent to psychiatric illness, such as stimulants used to treat hypersomnia in atypical depression, may mask a primary sleep disorder (e.g. obstructive sleep apnea or narcolepsy) that may be the true underlying cause of the sleep-related complaint.

Androgen effects

Future studies should aim for more powerful design, better focus on appropriate subgroups of men and end-points likely to benefit, and or alternative hormonal regimens. Pharmacological androgen therapy, using supraphysiological doses or novel synthetic androgens, might improve muscle, bone or other androgen-dependent functions in older men regardless of androgen deficiency status, nature or dose of androgen. Viewed like any other anti-ageing treatment, this would require evidence of efficacy, safety and cost-effectiveness from controlled trials rather then relying on supposed replacement status to lighten the burden of proof for efficacy and safety. This approach would diversify androgen therapies to allow enhanced targeting of androgen therapy via exploiting variations in tissue selectivity and metabolic activation (5a reduction, aromatization) profiles (Sundaram et al 1994) that could be developed in novel potent designer androgens (Dalton et al 1998, Edwards et al 1998). Regardless...

Childhood Obesity

As discussed in the Childhood Obesity section above, childhood obesity has reached epidemic proportions and continues to rise worldwide. Unfortunately, obesity-associated disease risk factors present in adults also manifest in obese children. For example, approximately 60 of overweight children in the Bogalusa Heart Study had one cardiovascular risk factor such as hypertension, hyperlipidemia, or hyperinsulinemia, and more than 20 of overweight children had two or more risk factors (78). Equally alarming is a study conducted in the Cincinnati area, which revealed a tenfold increase between 1982 and 1994 in the incidence of type 2 DM among adolescents (79). In fact, type 2 DM was reported to account for nearly 40 of all cases of new-onset DM in this age group. Furthermore, children are especially vulnerable to the psychological and behavioral consequences of obesity. Other comorbidities afflicting this age group include orthopedic and neurologic problems, sleep apnea, and hepatic and...

Respiratory Disease

Respiratory complications contribute significantly to morbidity and mortality in acromegaly, accounting for 25 of deaths (25). Both upper airway obstruction as well as central respiratory depression contribute to respiratory complication. Prognathism, macroglossia, hypertrophied nasal structures, tracheal calcification, and cricoarytenoid joint arthopathy contribute to significant upper airway obstruction (31-33). Laryngeal mucosal and cartilaginous hypertrophy leads to vocal cord fixation and laryngeal stenosis with accompanying voice change (31). These factors contribute to the difficulty in tracheal intubation often encountered in patients undergoing anesthesia. Central respiratory center depression, as well as upper airway obstruction, can result in sleep apnea and excessive snoring and also contribute to paroxysmal daytime sleepiness (narcolepsy) (31).

Memory

There is less consistency in studies of short-term and long-term memory functioning in OSA patients 32,34,44,45 . Bedard and colleagues described diminished performance on short-term memory in patients with moderate and severe sleep apnea, although only the severe group demonstrated evidence of impairment in delayed recall. These memory disturbances were associated with a decrease in vigilance 34 . Others have reported short- and long-term memory problems 38,46-49 . On the other hand, Greenberg and colleagues found no differences between patients with OSA and controls on subscales of the Wechsler memory scale (in either immediate or delayed conditions) 37 .

Anxiety and SRBD

Borak and colleagues reported an association between anxiety and OSA, but CPAP treatment did not improve patients' anxiety scores 22 . Several researchers found that high anxiety or depression contribute to non-compliance with CPAP treatment 124-127 . Such symptoms may leave patients less tolerant of the equipment. Some patients express claustrophobic anxiety when wearing a CPAP mask 128,129 . Hence, treatment of their anxiety symptoms as well as patient trial of diverse types of CPAP masks may be necessary to insure improved compliance with CPAP treatment.

Sedative hypnotics

Experts recommend caution in prescribing hypnotics to patients with severe OSA, especially those with daytime hypoventilation or hypercapneic chronic obstructive pulmonary disease (COPD), unless such patients are simultaneously effectively treated with CPAP. Benzodiazepines can decrease respiratory effort, upper airway muscle tone, and blunt arousal responses to hypoxia hypercapnia 144,145 . They may thus worsen sleep apnea 146 . Long-acting benzodiazepines such as flurazepam 146 and nitrazepam 147 produce the most marked respiratory depression. Thus, it is recommended that benzodiazepine hypnotics be used cautiously in OSA patients with compromised respiratory function 148 . If sedative hypnotic therapy is needed in patients with OSA, it is very important for clinicians to ensure CPAP adherence by periodic monitoring of compliance. Berry and colleagues reported that triazo-lam 0.25 mg increases the arousal threshold to airway occlusion, but this results in only modest prolongation of...

Modafinil

Medications can be used as an adjunctive treatment in OSA. Approximately 40 of patients do not tolerate CPAP, and patients with OSA treated with CPAP may still have daytime sleepiness. If CPAP treatment is being used optimally and daytime sleepiness persists, wakefulness-promoting medications (such as modafi-nil, amphetamines, and methylphenidate) may improve sleepiness and quality of life. Modafinil (Provigil ) is approved by the US Food and Drug Administration for residual excessive sleepiness in patients with obstructive sleep apnea syndrome after the CPAP regimen is optimized 162 . Modafinil is not approved for use in pediatric patients. In OSA, a concerted effort to treat with CPAP for an adequate period of time should be made prior to initiating modafinil or other wakefulness-promoting medications. If modafinil is used adjunct-ively with CPAP, encouragement and periodic assessment of CPAP compliance is necessary. Previous studies reported that modafinil (either with or without...

Acetazolamide

Acetazolamide has also been used in the treatment of certain pulmonary disorders. In patients with central sleep apnea, induction of systemic acidosis with acetazolamide may prove effective in stimulating the respiratory center and reducing the number of apneic episodes. High altitude pulmonary edema can be prevented in susceptible individuals by prophylactic administration of acetazolamide. While the mechanism of this protective effect is multifactorial, the development of metabolic acidosis stimulates the respiratory center and has favorable effects on the oxygen disassociation curve.

Excessive sleepiness

Actually represent sleepiness that is identical to that of other sleep disorders such as untreated obstructive sleep apnea or sleep deprivation 17 . Epworth sleepiness scale scores of > 15 are common in untreated patients 4,17,20 . The irresistible urge to sleep commonly occurs in inappropriate or dangerous situations and thus produces significant social and occupational dysfunction. While the ICSD-2 specifies an MSLT mean sleep latency of less than 8 minutes as support for the diagnosis of narcolepsy, narcolepsy patients commonly evidence much shorter mean sleep latencies of less than 5 minutes (Table 9.1).

Sleep paralysis

Sleep paralysis is the inability to move, lasting from a few seconds to minutes, during the transition from sleep to wakefulness or from wakefulness to sleep. Episodes of sleep paralysis may alarm patients, particularly those who experience the sensation of being unable to breathe. This occurs because accessory respiratory muscles may not be active during these episodes however, diaphragmatic activity continues and air exchange remains adequate. Sleep paralysis, like excessive sleepiness and hypnagogic and hypnopompic hallucinations, is not specific to narcolepsy and is often seen with various disorders that cause excessive sleepiness (sleep apnea or chronic sleep deprivation). Additionally, sleep paralysis is not necessarily indicative of pathology, but may be more common in patients with mood and anxiety disorders 30 .

Endocrine disorders

Patients with chronic endocrine disorders may complain of EDS. Sleepiness is a well-recognized symptom of hypothyroidism. Additionally, hypothyroidism has been reported as a risk factor for the development of obstructive sleep apnea 75 . It is not clear in some patients with hypothyroidism whether the sleepiness they experience is due to a direct effect of the hypothy-roid state or to a co-existing SRBD. Patients with acromegaly have also been shown to have an increased prevalence of sleep apnea, with reported rates from 39 to 58.8 76,77 . On the other hand, patients with growth hormone deficiency consistently report low energy, fatigue, and impaired sleep quality 78 .

Treatment of SWST

Figure 10.2 (a) Oximetry tracing from an obese 38 year old woman showing frequent desaturations of oxyhemoglobin, reaching a nadir of < 60 during polysomnographically documented non REM sleep, secondary to obstructive sleep apnea. Apnea and hypopnea events occurred at a rate of 80 per hour of sleep. Each desaturation is accompanied by evidence of arousal from sleep on the corresponding polysomnogram. She had complained of frequent spells of SW, which included eating foods from her cupboards and refrigerator. She responded wellto CPAP at 8 9cmH2O pressure, with resolution of obstructive sleep apnea and SW. See plate section for color version. (b) Polysomnogram corresponding to 2 minutes of sleep during baseline recording of sleep in the case of a 38 year old obese woman with obstructive sleep apnea, demonstrated by reduction of oral nasal airflow in the presence of respiratory effort noted by deflections representing chest and abdominal movements. The ensuing arousals from sleep...

Obesity In Children

Childhood obesity is associated with significant risk for health and psychological problems. A review of relevant literature reveals that obese children are more likely to develop hypertension, diabetes, and sleep apnea (Dietz, 1998). Twenty percent of overweight children have two or more of these problems. Further, being obese as a child greatly increases one's likelihood of being obese as an adult the probability increases with the severity of the childhood overweight condition, and leads to future health threats including possible increased risk for coronary heart disease, colon caner, and diabetes, as well as an associated increased risk of mortality (Dietz, 2002). Obesity in children can also carry a significant risk of social discrimination and psychological problems. Children tend to equate obesity with laziness and sloppiness and view obese children as less attractive, less intelligent, and less popular (Birch & Fisher, 1998). Further, obese children tend to suffer from...

Sleep architecture

In older individuals the presence of medical ailments as well as primary sleep disorders (e.g. sleep apnea) makes it more difficult to identify sleep changes related to normal aging. Elderly subjects show difficulty initiating and maintaining sleep, experience early awakenings, tend to nap during the daytime, and get sleepy earlier in the evening 64 . Altogether, ability to maintain consolidated sleep decreases with age, although it is unclear whether sleep need does. From early adulthood into late life SWS declines progressively from 20 to 3.5 , whereas REM sleep is only slightly reduced. However, older individuals with disorders of the central nervous system, including Alzheimer's disease and other dementias, show a significant decrease in REM sleep as well as fragmentation of the sleep-waking cycle 74 .

Depression in OSA

A number of studies, using varied designs, report an association between OSA and depression, based on elevated co-morbidity of OSA and MDD 30,70,72-74 , as well as increased levels of depressive symptoms 75-80 that do not necessarily reflect a major depressive episode 73 . Other studies observe a correlation between apnea-hypopnea index (AHI number of apneas and hypopneas per hour of sleep) and depression 81 , with increased depressive symptoms found in association with more severe SRBD 82 , and improvement of depressive symptoms after treatment with CPAP, uvulopalatopharyn-goplasty, or tracheostomy 74,76,77,79,83 . Peppard and colleagues found a dose-response association between SRBD severity (AHI) and depression in their population-based, longitudinal investigation (see Figure 7.3). Figure 7.3 compares the rates of depression found amongst individuals with differing levels of respiratory disturbance. Depression was defined as a score of 50 or higher on the Zung depression scale in...

Arthropathy

Arthropathy With Acromegaly

Left-ventricular hypertrophy Asymmetric septal hypertrophy Hypertension Congestive heart failure Sleep disturbances Sleep apnea Narcolepsy Visceromegaly Tongue Thyroid Salivary gland Liver Spleen Kidney Endocrine-metabolic Reproduction Widely spaced teeth, thickened tissue, persistent headache, sleep apnea snoring, amenorrhea impotence, colon polyps, unexplained prolactin